Lipid Management in Chronic Kidney Disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2013 Clinical Practice Guideline

Perspective:

The following are 10 points to remember about this guideline synopsis:

1. This guideline updates the 2003 Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease (CKD). The overall objective for the guideline is to inform the management of dyslipidemia and use of cholesterol-lowering medications in all adults and children with known CKD (defined by reduced estimated glomerular filtration rate [eGFR] or markers of kidney damage, such as abnormal albuminuria).

2. The clinical benefits of statin treatment are proportional to baseline coronary risk rather than baseline low-density lipoprotein cholesterol (LDL-C). LDL-C is not suitable for assessing coronary risk in persons with CKD: Although higher levels of LDL-C are associated with higher risk, dialysis patients with the lowest levels of LDL-C and total cholesterol are also at very high risk for all-cause and cardiovascular mortality. Among persons with non–dialysis-dependent CKD, the magnitude of the excess risk associated with increased LDL-C levels decreases at lower eGFRs.

3. The 10-year risk for coronary death or nonfatal myocardial infarction (MI) among CKD patients older than 50 years is consistently >10%, even in those without diabetes or previous MI. The working group suggests focusing on two factors: the absolute risk for coronary events and evidence that such treatment is beneficial. Key recommendations are listed below.

4. In adults ages ≥50 years with eGFR <60 ml/min/1.73 m2, but not treated with chronic dialysis or kidney transplantation (GFR categories G3a–G5), they recommend treatment with a statin or statin/ezetimibe combination. (1A)

5. In adults ages ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m2 (GFR categories G1–G2), they recommend treatment with a statin. (1B)

6. In adults ages 18–49 years with CKD, but not treated with chronic dialysis or kidney transplantation, they suggest statin treatment in people with one or more of the following (2A): known coronary disease (MI or coronary revascularization), diabetes mellitus, prior ischemic stroke, estimated 10-year incidence of coronary death or nonfatal, and/or MI >10%.

7. In adults with dialysis-dependent CKD, they suggest that statins or statin/ezetimibe combination not be initiated. (2A) In adults already receiving statins or statin/ezetimibe combination at the time of dialysis initiation, they suggest that these agents be continued. (2C) Several large randomized trials have not shown a conclusive benefit of statin treatment (alone or in combination) among prevalent dialysis patients. Even if statins truly do prevent cardiovascular events in prevalent dialysis patients, the magnitude of any relative reduction in risk seems substantially smaller than in earlier stages of CKD, although this may still translate into a clinically meaningful absolute benefit. Patients may reasonably choose statin treatment if they are interested in a relatively small, uncertain reduction in cardiovascular events. Other factors that may influence a patient’s decision to receive a statin could include elevated LDL-C, recent MI or greater life expectancy (both favoring treatment), and more severe comorbidity or higher current pill burden (both favoring nontreatment).

8. In adult kidney transplant recipients, they suggest treatment with a statin. (2B)

9. In adults with newly identified CKD (including those treated with chronic dialysis or kidney transplantation), they recommend evaluation with a lipid profile (total cholesterol, LDL-C, HDL-C, triglycerides). (1C) In adults with CKD (including those treated with chronic dialysis or kidney transplantation), follow-up measurement of lipid levels is not required for the majority of patients. (Not Graded) Because higher cardiovascular risk rather than elevated LDL-C levels is now the primary indication to initiate or adjust lipid-lowering treatment in CKD patients, follow-up monitoring of LDL-C (after an initial measurement) may not be required for many patients—especially given normal variability in LDL-C levels over time, which reduces the clinical utility of follow-up measurements.

10. In the judgment of the work group, follow-up measurement of lipid levels should be reserved for instances in which the results would alter management. Potential reasons to measure LDL-C (or the lipid profile) in persons with CKD after their initial presentation may include assessment of adherence to statin treatment, change in renal replacement method or concern about the presence of new secondary causes of dyslipidemia, or assessment of 10-year cardiovascular risk in patients younger than 50 years who are not currently receiving a statin. In the judgment of the work group, it is unnecessary to measure LDL-C in situations in which the results would not (or likely would not) change management.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Novel Agents, Statins

Keywords: Myocardial Infarction, Kidney Transplantation, Stroke, Follow-Up Studies, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Comorbidity, Coronary Disease, Risk Factors, Cholesterol, Renal Dialysis, Dyslipidemias, Azetidines, Cardiovascular Diseases, Glomerular Filtration Rate, Triglycerides, Diabetes Mellitus, Renal Insufficiency, Chronic


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